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<div class="head1 ">
<p><h1 id="head111">DOWNER</h1></p>
<p><h2 id="head11">Contractor Evaluation Form </h2> </p>
<br>
<p><HR id=head11 align=center width=80%  color=#000000 SIZE=5>
</HR></p>
<br>
<br>
</div>

<div class="instru ">
<p><strong>INSTRUCTIONS FOR CONTRACTORS COMPLETING THIS FORM:</strong></p>
<p>1. Contractor to complete all relevant sections of the form below and attach supporting documentation</p>
<p>2. Ensure responsibilities specified in Part C are communicated to all relevant persons engaged by your company and sign-off Part D of the form upon completion; </p>
<p>3. Forward the completed form (and supporting documentation) to the nominated Downer Infrastructure contact person. </p>
<p>4. Refer<strong> DA-ZH-PR022 Visitor and Contractor Management and DA-ZH-FM022.5 Contractor Evaluation Guidance</strong> for further information. </p>
    
</div>

<table class="table1" >
    
    <tr >
        <th colspan="7">
            PART A: COMPANY DETAILS 
        </th>

    </tr>

    <tr>
        <td style="background-color: #eeeeee">
        Company Name: (Trading Name ) 
        </td>
        <td colspan="3">
        
    
        </td>
        <td style="background-color: #eeeeee">
        ABN:
    
        </td>
        <td colspan="2" >
       
        </td>
        
        


    </tr>

    <tr>
        <td style="background-color: #eeeeee" >
        Legal/Entity name If any other than the trading Name 
        </td>
        <td colspan="3">
        
        </td >
        <td style="background-color: #eeeeee">
            
           Name Match ABR website  
        </td>
        <td>
             <input type="radio"  name="111" value="111" />YES

        </td>
        <td>
             <input type="radio"  name="111" value="222" />NO,<i style="color: blue"> certificate of registration must be attached </i>

        </td>


    </tr>
    <tr>



            <td style="background-color: #eeeeee">
         Contact Person:
    
        </td>
        <td width="100px">
            
        
        </td >
        <td width="50px" style="background-color: #eeeeee">
            
           E-Mail 
        </td>
        <td width="150px" >
            
             
        </td>
        <td style="background-color: #eeeeee">
            
            Address
        </td>
        <td width="200px" colspan="2">
            
            
        </td>





    </tr>


    <tr>



            <td  style="background-color: #eeeeee">
         Telephone:
    
        </td>
        <td >
            
            
        </td>
        <td colspan="2" rowspan="2" style="background-color: #eeeeee">
           Emergency Contact Details 
        
        </td >
        <td  style="background-color: #eeeeee">
            
            Name 
        </td>
        <td  colspan="2">
            
             
        </td>
        <tr>
            <td style="background-color: #eeeeee">
                Fax

             </td>

             <td>
                 
             </td>
             <td style="background-color: #eeeeee">
                Address and Phone number
              </td>
              <td colspan="2">
                  
              </td>


        </tr>





    


</table>
<br>
<br>

<br>


<table class="table2">
    
<tr>
    
<th colspan="5">PART B: INSURANCE DETAILS</th>



</tr>

<tr>
<td rowspan="4">
1. Does your company have Public Liability Insurance? 
</td>

<td colspan="3">
     <input type="radio"  name="222" value="2222" />YES <i style="color: blue">Attach Certificate of Currency </i>
   

    
</td>
<td rowspan="4">
    
<input type="radio"  name="222" value="222" />NO

</td>
</tr>
<tr>
    <td>
        

        Specify third party liability sum insured:
    </td>
    <td>
        AU$
    </td>
    <td width="150px">
</tr>   
<tr>
    </td>

    <td>
        Insurer
    </td>


    <td>

    Validity Date:
    </td>


    <td>
        Policy No: 
    </td>


</tr>
<tr>
<td height="50px"> </td>
<td> </td>
<td> </td>
</tr>


<tr>
    <td rowspan="2">
        
        2. Do the services you provide involve the transportation of Downer Infrastructure plant/equipment? 

    </td>

    <td colspan="3"> 
      <input type="radio"  name="333" value="2222" />
       Yes Does your Public Liability policy include a carriers liability extension to cover the damage/loss of Downer Infrastructure property?
        

    </td>
    <td rowspan="2">
        
    <input type="radio"  name="222" value="222" />NO

    </td>



</tr>

<tr>
    <td>
        <input type="radio"  name="333" value="333" />yes
        <input type="radio"  name="333" value="333" />NO
        <i style="color: blue"> If Yes, specify the sum insured:  </i>


    </td>
    <td>
        AU$
    </td>
    <td>
        

    </td>


</tr>



<tr>
    <td rowspan="3">
        
        3. Does your company have Workers Compensation Insurance? 

    </td>

    <td colspan="2">
         <input type="radio"  name="444" value="444" />YES
        <i style="color: blue">  Attach Certificate of Currency   </i>
    </td>
    <td>
        <input type="radio"  name="555" value="555" />NO

    </td>
    <td rowspan="3">
        <input type="radio"  name="555" value="555" />NA
        <i style="color: blue"> (Only if Sole Trader) </i>


    </td>

</tr>

<tr>
    <td>
        Insurer
    </td>
    <td>
        Validity Date 

    </td>
    <td>
        
        Policy No
    </td>


</tr>


<tr>
    
<td height="40px"></td>
<td></td>
<td></td>

</tr>
<tr>
    <td rowspan="3">
        
       4. Do you have Comprehensive Motor Vehicle Insurance?<i style="color: blue">** Applicable where work involves the use of a vehicle on site</i>
    </td>

    <td colspan="2">
         <input type="radio"  name="444" value="444" />YES
        <i style="color: blue">   Attach Certificate of Currency    </i>
    </td>
    <td>
        <input type="radio"  name="555" value="555" />NO

    </td>
    <td rowspan="3">
        <input type="radio"  name="555" value="555" />NA
       


    </td>

</tr>
<tr>
    <td>
        Insurer
    </td>
    <td>
        Validity Date 

    </td>
    <td>
        
        Policy No
    </td>


</tr>


<tr>
    
<td height="40px"></td>
<td></td>
<td></td>

</tr>
<tr>
    <td rowspan="3">
        
        5. Does your business have Transit Insurance? <i style="color: blue">** Applicable where work involves the transportation of Downer Infrastructure plant/equipment and damage/loss is not otherwise covered by Public Liability Insurance detailed above 
 </i>
    </td>

    <td colspan="2">
         <input type="radio"  name="444" value="444" />YES
        <i style="color: blue">   Attach Certificate of Currency    </i>
    </td>
    <td>
        <input type="radio"  name="555" value="555" />NO

    </td>
    <td rowspan="3">
        <input type="radio"  name="555" value="555" />NA
       


    </td>

</tr>
<tr>
    <td>
        Insurer
    </td>
    <td>
        Validity Date 

    </td>
    <td>
        
        Policy No
    </td>


</tr>


<tr>
    
<td height="40px"></td>
<td></td>
<td></td>

</tr>
<tr>
    <td rowspan="3">
        
       6. Does your business have Professional Indemnity Insurance? 
    </td>

    <td colspan="2">
         <input type="radio"  name="444" value="444" />YES
        <i style="color: blue">   Attach Certificate of Currency    </i>
    </td>
    <td>
        <input type="radio"  name="555" value="555" />NO

    </td>
    <td rowspan="3">
        <input type="radio"  name="555" value="555" />NA
       


    </td>

</tr>
<tr>
    <td>
        Insurer
    </td>
    <td>
        Validity Date 

    </td>
    <td>
        
        Policy No
    </td>


</tr>


<tr>
    
<td height="40px"></td>
<td></td>
<td></td>

</tr>


</table>
<br><br>


<table class="table3">
    <tr>
        <th colspan="3" >
            PART C: ZERO HARM MANAGEMENT SYSTEMS (SAFETY/ENVIRONMENT AND QUALITY)<i style="color: blue">** Indicate if your business is a contractor to Downer Infrastructure and complete the corresponding questionnaire below:  </i>

        </th>


    </tr>
     <tr>
        <th colspan="3">
            CONTRACTOR TO COMPLETE 
        </th>


    </tr>
    
    <tr>
        <td>1. Briefly describe the nature of work you conduct for Downer Infrastructur</td>
        <td colspan="2"></td>



    </tr>
    <tr>
        <td colspan="3">2. Are any of the following activities associated with the work you perform: <i style="color: blue"> Tick all that apply.  </i></td>


    </tr>
    <tr>
        <td>
            
         <p><input type="radio"  name="444" value="444" /> 
         Operation of mobile plant or heavy vehicles </p>
         <p><input type="radio"  name="444" value="444" /> 
         Operation of cranes or lifting equipment  </p>
        <p> <input type="radio"  name="444" value="444" />
         Operation of fixed plant or powered hand tools </p>
        <p> <input type="radio"  name="444" value="444" /> 
         Excavation / trenching </p>

        </td>

         <td>
            <p><input type="radio"  name="444" value="444" />  
          Confined Space Entry  </p>
           <p><input type="radio"  name="444" value="444" /> 
            Electrical work  </p>
             <p><input type="radio"  name="444" value="444" /> 
                Traffic management services </p> 
                 <p><input type="radio"  name="444" value="444" /> 
                    Hot work </p> 
                     <p><input type="radio"  name="444" value="444" /> 
                        Work at heights  Manual handling 
                        </p>

        </td>
        <td>
         <p><input type="radio"  name="444" value="444" />  
            Emission of high noise   </p>
            <p><input type="radio"  name="444" value="444" />  
                Disposal of Trade Waste </p> 
                 <p><input type="radio"  name="444" value="444" />  
                    Emissions to air, water or land   </p>
                    <p><input type="radio"  name="444" value="444" />  
                        Use or transport of hazardous / dangerous goods  </p>
                        <p><input type="radio"  name="444" value="444" />  
                         Asbestos removal / transport </p>

       </td>



    </tr>

    <tr>
        <td colspan="2">
            3. Approximate number of employees who may directly undertake work for Downer Infrastructure: 
        </td>
        <td></td>
        




    </tr>
    <tr>
        <td>4. Will you engage subcontractors to provide services to Downer Infrastructure</td>
        <td><input type="radio"  name="01" value="01" />  
            YES,<i style="color: blue"> list name[s] of subcontracting companies:   </i> </td>
            <td><input type="radio"  name="01" value="02" />No</td>




    </tr>
    <tr>
        <td>5. Do your workers hold the necessary licence and/or qualifications for the proposed work? (e.g. mobile plant & heavy vehicle operation) </td>
        <td><input type="radio"  name="01" value="01" />  
            YES,<i style="color: blue">  attach copies or a register of licences    </i> </td>
            <td><input type="radio"  name="01" value="02" />No</td>









     </tr>
    <tr>
        <td>6. Do you have an OHS Management system? </td>
        <td><input type="radio"  name="01" value="01" />  
            YES</td>
            <td><input type="radio"  name="01" value="02" />No</td>




    




    </tr>

 </tr>
    <tr>
        <td><i style="color: blue">  If “Yes”, is your system accredited to an external Safety standard (e.g. SafetyMap, AS4801)    </i>  </td>
        <td><input type="radio"  name="01" value="01" />  
            YES,<i style="color: blue">  attach copies or a register of licences    </i> </td>
            <td><input type="radio"  name="01" value="02" />No</td>




    




    </tr>

 </tr>
    <tr>
        <td>7. Do you have an Environmental Management system </td>
        <td><input type="radio"  name="01" value="01" />  
            YES</td>
            <td><input type="radio"  name="01" value="02" />No</td>




    




    </tr>

 </tr>
    <tr>
        <td><i style="color: blue">  If “Yes”, is your system accredited to an external environmental standard (e.g. ISO 14001).   </i>  </td>
        <td><input type="radio"  name="01" value="01" />  
            YES,<i style="color: blue">  attach copies or a register of licences    </i> </td>
            <td><input type="radio"  name="01" value="02" />No</td>




    




    </tr>

 </tr>
    <tr>
        <td>8. Do you have a Quality Management System? </td>
        <td><input type="radio"  name="01" value="01" />  
            YES</td>
            <td><input type="radio"  name="01" value="02" />No</td>




    




    </tr>

 
    <tr>
        <td><i style="color: blue">  If “Yes”, is your system accredited to an external quality standard (e.g. ISO 9001).   </i></td>
        <td><input type="radio"  name="01" value="01" />  
            YES,<i style="color: blue">  attach copies or a register of licences    </i> </td>
            <td><input type="radio"  name="01" value="02" />No</td>




    




    </tr>


    <tr>
        <td colspan="3">9. Do you have processes/systems in place for: </td>
        



    




    </tr>


    <tr>
        <td>The reporting & correction of incidents, hazards & non-conformances; </td>
        <td><input type="radio"  name="01" value="01" />  
            YES</td>
            <td><input type="radio"  name="01" value="02" />No</td>




    




    </tr>
     <tr>
        <td>The identification & delivery of WHS & environmental training needs; </td>
        <td><input type="radio"  name="01" value="01" />  
            YES</td>
            <td><input type="radio"  name="01" value="02" />No</td>




    




    </tr>
     <tr>
        <td>Monitoring & analysing safety, quality and environmental performance.</td>
        <td><input type="radio"  name="01" value="01" />  
            YES</td>
            <td><input type="radio"  name="01" value="02" />No</td>




    




    </tr>
     <tr>
        <td>Fatigue management </td>
        <td><input type="radio"  name="01" value="01" />  
            YES
        <input type="radio"  name="01" value="02" />No</td>

            <td><input type="radio"  name="01" value="02" />NA</td>


        </tr>
         <tr>
        <td>Injury management </td>
        <td><input type="radio"  name="01" value="01" />  
            YES
        <input type="radio"  name="01" value="02" />No</td>

            <td><input type="radio"  name="01" value="02" />NA</td>


        </tr>
        <tr>
        <td colspan="3">10. Do you have the following documentation to support your systems </td>
        
    </tr>
    <tr>
        <td>Safety & Environmental Management Policies; </td>
        <td><input type="radio"  name="01" value="01" />  
            YES<i style="color: blue">  Attach </i></td>
            <td><input type="radio"  name="01" value="02" />No</td>


    
    </tr>
    <tr>
        <td>An Safety / Environment Plan for the proposed work; </td>
        <td><input type="radio"  name="01" value="01" />  
            YES<i style="color: blue">  Attach </i></td>
            <td><input type="radio"  name="01" value="02" />No</td>


    
    </tr>

<tr>
        <td>Procedures / SWMS for activities indicated at [2]; </td>
        <td><input type="radio"  name="01" value="01" />  
            YES<i style="color: blue">  Attach </i></td>
            <td><input type="radio"  name="01" value="02" />No</td>


    
    </tr>

<tr>
        <td>Risk assessments for plant and Hazardous Substances to be used during work for Downer Infrastructure;  </td>
        <td><input type="radio"  name="01" value="01" />  
            YES<i style="color: blue">  Attach </i></td>
            <td><input type="radio"  name="01" value="02" />No</td>


    
    </tr>

<tr>
        <td>SDS for Hazardous Substances & Dangerous Goods to be used or transported </td>
        <td><input type="radio"  name="01" value="01" />  
            YES<i style="color: blue">  Attach </i></td>
            <td><input type="radio"  name="01" value="02" />No</td>


    
    </tr>
<tr>
        <td>Records of employee training and competency;</td>
        <td><input type="radio"  name="01" value="01" />  
            YES<i style="color: blue">  Attach </i></td>
            <td><input type="radio"  name="01" value="02" />No</td>


    
    </tr>
<tr>
        <td>Records of scheduled preventative maintenance for plant/equipment to be used in the delivery of services; </td>
        <td><input type="radio"  name="01" value="01" />  
            YES<i style="color: blue">  Attach </i></td>
            <td><input type="radio"  name="01" value="02" />No</td>


    
    </tr>
<tr>
        <td>Records of typical daily pre-start inspections on all plant / equipment to be used in the delivery of services; 
 </td>
        <td><input type="radio"  name="01" value="01" />  
            YES<i style="color: blue">  Attach </i></td>
            <td><input type="radio"  name="01" value="02" />No</td>


    
    </tr>
<tr>
        <td>Emergency procedures (e.g. fire / first aid / spill response). </td>
        <td><input type="radio"  name="01" value="01" />  
            YES<i style="color: blue">  Attach </i></td>
            <td><input type="radio"  name="01" value="02" />No</td>


    
    </tr>
     <tr>
        <td colspan="3">11. Have you, or your company been the subject of: </td>
        
    </tr>
    <tr>
        <td>Safety or Environmental conviction;  </td>
        <td><input type="radio"  name="01" value="01" />  
            YES<i style="color: blue">   attach detail of offence[s] </i></td>
            <td><input type="radio"  name="01" value="02" />No</td>


    
    </tr>
    <tr>
        <td>Prohibition or penalty notices from Safety or Environmental Authorities. </td>
        <td><input type="radio"  name="01" value="01" />  
            YES<i style="color: blue">   attach detail of offence[s]  </i></td>
            <td><input type="radio"  name="01" value="02" />No</td>


    
    </tr>




</table>

<div>
<table class="table4">
    

<tr>
    <th>
        CONTRACTOR TO COMPLETE 


    </th>


</tr>

<tr>
    <td height="900">
        <p>12. Upon engagement by Downer, you are required to abide by the following conditions:</p>
       
        <p><u>General Contractor Responsibilities: </u></p>
        <p> Immediately cease, and report, any workplace activity that presents an immediate risk to safety, property or environment; </p>
        <p> Under no circumstances engage in workplace activity which may jeopardise the safety of themselves or others; </p>
        <p> Seek immediate assistance from their Downer Infrastructure Supervisor before undertaking tasks they are unfamiliar with, or lack the proper training to conduct; </p>
        <p> Where required by law, possess the necessary license, certificate or qualification to undertake their work;</p>
        <p> Present for work in a fit and proper state, free from the effects of alcohol or drugs; </p>
        <p> Comply with relevant Safety legislation, Standards, Codes and Workers Compensation/Rehabilitation legislation; </p>
        <p> Comply fully with instruction & training provided by Downer Infrastructure; </p>
        <p> Ensure the integrity of safety devices are not bypassed or defeated; </p>
        <p> Immediately report hazards & incidents to their Downer Infrastructure Supervisor; </p>
        <p> Participate in toolbox talks & training as required by Downer Infrastructure; </p>
        <p> Participate in incident investigations, risk assessments, inspections and audits as required by Downer Infrastructure. </p>
        <p><u>Supply, Use & Maintenance of Plant & Equipment </u></p>
        <p> Ensure plant & equipment is fit for purpose, free from damage or defects that could result in injury, property damage or environmental harm; </p>
        <p> Ensure plant/equipment is designed and maintained in accordance with relevant legislation, standards and codes; </p>
        <p> Ensure plant and equipment is subject to appropriate inspection and maintenance; </p>
        <p> Ensure electrical equipment is tagged and tested in accordance with legislation</p>
        <p><u>Supply, Use & Maintenance of Hazardous Substances & Dangerous Goods </u></p>
        <p> Ensure a current SDS is supplied to Downer Infrastructure and available at the point of substance use and storage; </p>
        <p> Ensure a risk assessment on the use, handling, transport and storage is supplied to Downer Infrastructure</p>
        <p> Ensure containers are correctly labeled and appropriate for the nature of substance; </p>

        <p> Ensure volumes stored on site are kept as low as reasonably practicable; </p>
        <p> Ensure provisions are available for the immediate, safe and environmentally sound clean-up of spills. </p>








    </td>


</tr>






</table>

<table class="table5">
    <tr>
        <th>
            CONTRACTOR TO COMPLETE 
        </th>
    </tr>

    <tr>
        <td height="900px"></td>
        



    </tr>




</table>

</div> 



<table class="table6">
    <tr>
        <th colspan="4">
            PART D: CONTRACTOR  DECLARATION 
        </th>

    </tr>


    <tr>
        <td colspan="4">
            <p> I hereby declare the information provided above is a true and accurate reflection of my Company’s management systems. </p>
            <p> I agree to ensure compliance with my company’s management systems and instruction issued by Downer Infrastructure during the course of work. </p>
            <p> I understand my responsibilities as a Contractor to Downer Infrastructure, and will communicate these to persons under my control. </p>
            <p> By submitting this form I consent to the terms of the Downer Privacy Policy, including to the collection, storage, use and disclosure (including cross-border disclosure) of my personal information in the manner indicated in that policy and, where I have provided information about another individual, I confirm that I have obtained the consent of that individual in the manner required in that policy. </p>


        </td>

    </tr>
    <tr>
        <td>Name of person completing this form:</td>
        <td width="220px"> </td>
        <td>Signature: </td>
        <td width="220px"> </td>



    </tr>
     <tr>
        <td>Position held in company:</td>
        <td width="220px"> </td>
        <td>Date: </td>
        <td width="220px"> </td>



    </tr>


</table>

<table class="table7">
    <tr>
        <th>
          INTERNAL USE ONLY

        </th>
        <th colspan="2">PART E: OTHER REQUIREMENTS </th>
        <th colspan="2">INTERNAL USE ONLY </th>
    </tr>
    <tr>
        <td colspan="5">
            List other requirements specific to the project or division

        </td>


    </tr>

    <tr>
        <td></td>
        <td colspan="2"> 
            <input type="radio"  name="01" value="01" />
            YES<i style="color: blue">   Attach document or evidence </i>
        </td>
        <td >
            <input type="radio"  name="01" value="01" />
            NO
            
        
        </td>
         <td >
            <input type="radio"  name="01" value="01" />
            NA
            
        
        </td>



    </tr>
    <tr>
        <td></td>
        <td colspan="2"> 
            <input type="radio"  name="01" value="01" />
            YES<i style="color: blue">   Attach document or evidence </i>
        </td>
        <td >
            <input type="radio"  name="01" value="01" />
            NO
            
        
        </td>
         <td >
            <input type="radio"  name="01" value="01" />
            NA
            
        
        </td>



    </tr>
    <tr>
        <td></td>
        <td colspan="2"> 
            <input type="radio"  name="01" value="01" />
            YES<i style="color: blue">   Attach document or evidence </i>
        </td>
        <td >
            <input type="radio"  name="01" value="01" />
            NO
            
        
        </td>
         <td >
            <input type="radio"  name="01" value="01" />
            NA
            
        
        </td>



    </tr>
    <tr>
        <td></td>
        <td colspan="2"> 
            <input type="radio"  name="01" value="01" />
            YES<i style="color: blue">   Attach document or evidence </i>
        </td>
        <td >
            <input type="radio"  name="01" value="01" />
            NO
            
        
        </td>
         <td >
            <input type="radio"  name="01" value="01" />
            NA
            
        
        </td>



    </tr>
    <tr>
        <td></td>
        <td colspan="2"> 
            <input type="radio"  name="01" value="01" />
            YES<i style="color: blue">   Attach document or evidence </i>
        </td>
        <td >
            <input type="radio"  name="01" value="01" />
            NO
            
        
        </td>
         <td >
            <input type="radio"  name="01" value="01" />
            NA
            
        
        </td>



    </tr>
    <tr>
        <td></td>
        <td colspan="2"> 
            <input type="radio"  name="01" value="01" />
            YES<i style="color: blue">   Attach document or evidence </i>
        </td>
        <td >
            <input type="radio"  name="01" value="01" />
            NO
            
        
        </td>
         <td >
            <input type="radio"  name="01" value="01" />
            NA
            
        
        </td>



    </tr>
    <tr>
        <td></td>
        <td colspan="2"> 
            <input type="radio"  name="01" value="01" />
            YES<i style="color: blue">   Attach document or evidence </i>
        </td>
        <td >
            <input type="radio"  name="01" value="01" />
            NO
            
        
        </td>
         <td >
            <input type="radio"  name="01" value="01" />
            NA
            
        
        </td>



    </tr>
    <tr>
        <td></td>
        <td colspan="2"> 
            <input type="radio"  name="01" value="01" />
            YES<i style="color: blue">   Attach document or evidence </i>
        </td>
        <td >
            <input type="radio"  name="01" value="01" />
            NO
            
        
        </td>
         <td >
            <input type="radio"  name="01" value="01" />
            NA
            
        
        </td>



    </tr>

    <tr>
        <td>
            Performance Rating:<i style="color: blue">Indicate the standard to which the Contractor meets requirements pertaining to insurances, Safety/Environmental/ Quality Management </i>
        </td>
        <td>
             <input type="radio"  name="01" value="01" />
            Acceptable


        </td>
         <td>
             <input type="radio"  name="01" value="01" />
            Unacceptable


        </td>
        <td colspan="2">
            <input type="radio"  name="01" value="01" />
           Acceptable with Conditions 

        </td>



    </tr>
    <tr>
        <td colspan="5">
            <i style="color: blue">** Ratings are acceptable: (refer DA-ZH-FM022.5 for guidance) indicate the Contractor is approved for use;
              </i>
              <p> <i style="color: blue">** Ratings are acceptable: (refer DA-ZH-FM022.5 for guidance) indicate the Contractor is approved for use;
              </i></p>

        </td>

    </tr>



</table>

<table class="table8">
    <tr>
    <th colspan="2">
        
        CONDITIONS / ACTION REQUIRED 
    </th>
    <th>
        RESPONSIBILITY
    </th>
    <th>
        COMPLETE (Y/N) 
    </th>
    </tr>



    <tr>
        <td colspan="2" height="28px"></td>
        <td></td>
        <td></td>
        

    </tr>

    <tr>
        <td colspan="2" height="28px"></td>
        <td></td>
        <td></td>
        

    </tr>
      <tr>
        <td colspan="2" height="28px"></td>
        <td></td>
        <td></td>
        

    </tr>
      <tr>
        <td colspan="2" height="28px"></td>
        <td></td>
        <td></td>
        

    </tr>
      <tr>
        <td colspan="2" height="28px"></td>
        <td></td>
        <td></td>
        

    </tr>
    <tr>
        <td>OVERALL RATING:</td>
        <td>
            <input type="radio"  name="01" value="01" />
           APPROVED

        </td>
        <td colspan="2">
            <input type="radio"  name="01" value="01" />
          REJECTED 

        </td>



    </tr>
    <tr>
        <td>Name and Position of person completing review:</td>
        <td></td>
        <td>Signature with date:</td>
        <td></td>


    </tr>
     <tr>
        <td>Name of Responsible Manager:</td>
        <td></td>
        <td>Signature with date:</td>
        <td></td>


    </tr>
     <tr>
        <td>Name of Authorised Person:</td>
        <td></td>
        <td>Signature with date:</td>
        <td></td>


    </tr>


</table>
<table>
    <tr>
        <th colspan="4">OFFICE USE ONLY </th>
    </tr>
    <tr>
        <td>Send to Administrator / Upload to:</td>
        <td colspan="2"><input type="radio"  name="01" value="01" />
             COINS, <i style="color: blue">   also complete CIS New Request Form</i>
         </td>
          <td ><input type="radio"  name="01" value="01" />
            MATRIX / JD Edwards 
         </td>


    </tr>
    <tr>
        <td>Vendor Number Assigned </td>
        <td width="200px"></td>
        <td>Date : </td>
        <td></td>



    </tr>


</table>

 </body>








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